Clin Endosc > Volume 55(5); 2022 > Article
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Park, Kim, and Yang: A subepithelial lesion in a patient with long-standing ulcerative colitis


A 59-year-old woman underwent surveillance colonoscopy for extensive ulcerative colitis (UC) diagnosed 20 years ago. She underwent colonoscopies annually for the last 5 years, but colorectal neoplasia was not observed. Colonoscopy revealed a broad spectrum of inflammatory lesions in whole segments, ranging from scar changes to active ulcerations. Additionally, a small subepithelial lesion was detected in the proximal rectum. The surface of this lesion showed mild erythematous changes (Fig. 1). On endoscopic ultrasonography (UM-3R; Olympus Medical, Tokyo, Japan), a 9.5×4.7 mm hypoechoic tumor was detected in the second and third layers of the rectal wall (Fig. 2). What is the most likely diagnosis?


Conflicts of Interest
Dong-Hoon Yang is currently serving as a section editor of Clinical Endoscopy; however, he had not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no potential conflicts of interest.
Author Contributions
Conceptualization: DHY; Investigations and visualization: SP, JK; Writing–original draft: SP, JK, DHY; Writing–review & editing: SP, JK, DHY.

Fig. 1.
Colonoscopy reveals an erythematous subepithelial lesion at the proximal rectum in the background of diffuse scar change.
Fig. 2.
On endoscopic ultrasonography, the tumor presents as a hypoechoic lesion confined within the mucosa and submucosa (yellow arrows) and obliterates the muscularis mucosae.
Fig. 3.
Histopathology of the forceps biopsy and endoscopic submucosal dissection specimens. (A) The forceps biopsy specimen shows well-differentiated adenocarcinoma with multifocal irregular glands and desmoplastic stroma (hematoxylin & eosin stain, ×20 objective lens). (B) The endoscopic submucosal dissection specimen shows poorly demarcated dysplasia (upper panel; hematoxylin & eosin staining, ×4 objective lens). A higher magnification of the rectangle clearly shows high-grade dysplasia (lower panel; hematoxylin & eosin staining, ×20 objective lens).
Fig. 4.
Another synchronous subepithelial lesion was suspected near the endoscopic submucosal dissection site. (A) White light endoscopy image (green arrows). (B) Forceps biopsy specimen shows irregularly shaped glands with marked nuclear pleomorphism that represents well-differentiated adenocarcinoma (hematoxylin & eosin staining, ×20).
Fig. 5.
Pathologic features of the resected specimen. (A) Two poorly demarcated hyperemic lesions (circles) are noted in the rectum near the distal resection margin. (B) Tumor sections from the upper circle show well-differentiated adenocarcinoma invading the deep submucosa (sm3) with abundant lymphocytic infiltration (hematoxylin & eosin staining, ×10). (C) The second tumor in the lower circle shows more irregular gland shape and thinner neoplastic cells than the first tumor (hematoxylin & eosin staining, ×10). (D) High-grade dysplasia between the two tumors (hematoxylin & eosin staining, ×20).


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